Basic Information
Provider Information | |||||||||
NPI: | 1982151650 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHARLOTTE OPCO HOLDINGS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EAST TOWNE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2568 | ||||||||
Address2: |   | ||||||||
City: | HICKORY | ||||||||
State: | NC | ||||||||
PostalCode: | 286032568 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8283225535 | ||||||||
FaxNumber: | 8283268115 | ||||||||
Practice Location | |||||||||
Address1: | 4815 N SHARON AMITY RD | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282054669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7045310948 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2016 | ||||||||
LastUpdateDate: | 11/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TREFZGER | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 8283225535 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | HAL060149 | NC | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 343900000X |   |   | N |   | Transportation Services | Non-emergency Medical Transport (VAN) |   | 311ZA0620X |   |   | Y |   | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
No ID Information.